31 Psychological interventions with people with dementia ne Bob Woods, Linda Clare University of Wales Bangor, Bangor, UK INTRODUCTION ‘This chapter is concerned with psychological approaches to working with people with dementia, The development of such approaches can be traced back over at least 50 years For example, Cosin and colleagues published an evaluation of social and domestic activity, and occupational therapy with people with ‘persistent senile confusion” in 19585 they noted increases in purposive, appropriate behaviour in response to this innovative programme. In this chapter we will deseribe the major approaches that have been developed subse~ quently, outline the evidence base in relation to their effectiveness and place psychological interventions in the broader context of care and support for the person with dementia. ‘There are a number of ways in which the various approaches might be grouped and categorized. For the purposes of this chapter, we will discuss them in relation to their main focus. Accordingly, we identify one group of approaches with an emphasis on stimulation of the senses and activity; a second group which focuses on the emotional world of the person with dementia; a third which aims to produce changes in behaviour and function; and a fourth group where the focus is on cognitive processes and function. These categories are not, of course, mutually exclusive, but they provide a useful way of considering the range of interventions. An approach with a particular focus may well aim to produce a different type of outcome; for example, a behavioural approach may aim (o reduce depressed mood; or a cognitive approach may aim to improve quality of life or day-to-day function. In this, chapter, we will not be considering several important areas which are covered in depth else where in the handbook: psychological interventions in response to challenging behaviour (Chapter 33), or interventions with family caregivers (Chapter 32) or changes tothe physical or social environment of a care setting (Chapter 17) Tn evaluating these intervention approaches, it is important to consider what changes will be of value to people with dementia and their supporters. A change of a few points ‘on a measure of cognitive function may be of theoretical interest, but unless it contributes: to changes in, say, the person’s wellbeing ot day-to-function, it may not merit intensive therapeutic input. On the other hand, if a person's anxiety and distress is reduced whilst Handbook of the Clinical Pechology of Aging. alte by tb Woods an Linda Che. © 2008 John Wiley & Sons 3522 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING Winocur, G., Craik, FIM, Levine, B. et al. (2007) Cognitive rehabilitation in the eldesly: overview ‘nd future directions. Journal of the International Neuropsyehological Society, 13(1), 166-71. Winocut,G., Palmer, H., Dawson, D. er af. (2007) Cognitive rehabilitation inthe elderly: an evaluation ‘of psychosocial factors. Jownal ofthe International Neuropsychologicad Society, 130), 153-65. ‘Wood, RL, & Worthington, A.D. (1999) Outcome in community rehubiltation: measaring the social impact of disability. Neuropsychological Rehabilitation, 93-4), 505-16. ‘World Health Organization (2007) Neurological Disorders: Public Health Challenges. World Wealth Organization Press, Genova,524 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING receiving a hand massage or listening to music, this may be worthwhile, even if the person's negative emotional state returns at the end of the session. In the context of a condition where progression of impairmentis typically seen, maintenance of function may be the appropriate goal, rather than improvement per se. In general, short-term interventions would be expected to have short-term effects; if treatment differences between intervention and control groups disappear at a follow-up evaluation, this may be seen as @ failure to build in a maintenance component to the intervention, rather than a weakness of the original intervention. Randomized controlled trials (RCTs) are now seen ax the gold standard in evaluating any intervention approach, but some caution is needed in relying only on RCTs in evaluating psychological approaches in dementia care (Woods, 2003). Psychological interventions cannot, of course, be double blind, in that the person must know which treatment they are receiving; whilst itis possible to arrange for those assessing the effects of the intervention to be independent from those offering the intervention, preventing the person with dementia, or carer talking about the intervention is not always possible! Interventions that cannot be neatly ‘packaged’, or which are highly individualized, are also more difficult to evaluate using an RCT. Ensuring equivalence of treatment across participants is also much more difficult than with a pill. Placebo interventions are possible, to allow for nonspecific effects of the intervention. However, pragmatically it is possible to argue that these nonspecific aspects in fact form an important part of any intervention. Most importantly, RCTs provide information about what ix effective for the average person with dementia, They provide little information about what will work for the individual person, and inereasingly, it is recognized that an intervention that is helpful for one individual may not be effective for the next. It is important, therefore, that we find ways of recognizing ‘what works for whom? and do not reject interventions because they do not work for everyone. It has been recognized for some time that the values and attitudes of those involved in delivering a psychological intervention can strongly influence its implementation, Nega- tive attitudes and the presence of what Kitwood (1990) described as a ‘malignant social psychology” can undermine and distort the application of any specific approach. For these approaches to be useful, they nust build on a culture of person-centered care (see Chapter 10, this volume), where the person with dementia is respected as an adult person of value and worth, with @ unique life history, individual preferences and needs, who is offered choices and supported in being as independent as possible. STIMULATION AND ACTIVITY APPROACHES These approaches arose from the notion that people with dementia are understimulated, receiving inadequate sensory input. Reduced sensory input may be experienced for several reasons: first, normal decline in sensory acuity; secondly, the monotonous environments in which some older people live; and thirdly, some people withdraw and reject stimulation, cutting themselves off from the environment, peshaps as a way of coping with perplexing, almost alien, surroundings. Support came from sensory deprivation experiments, showing that even young, healthy people suffered from cognitive and perceptual disturbances when deprived of sensory stimulation for an extended period of time (see Holden & Woods, 1995). Sensory deprivation results as much from monotony as from lack of stimulation. Sensory deprivation, it was argued, would be especially damaging to people with dementia as theiruosaud seas Sop oxy way ponordiay se sasmu Joeq 8 02 pasu aM, pur ‘sony JBNLUINY PoE SOLOMON 4oypIeO Jo [eaauiar amp 04 Buspna] sv UoDs st ‘sasso] A10StIaS (AN PouNqutod ‘KiowIoUE 19D9F JO SSO ‘Uy, “aouaseaNaT pute ossmUE Zursn sw Jam SP — 99!0R Jo au oRTUOD aka “yanon Jo ast = wonvotunuuuroa jeqrexuou Jo sjoadsv Aucur epayour sanbrryoay oyroods ou ‘suonENNs yo sodéi remmopand ur Jajdjoy ssoj so auour aq Avur Feym OVUL SHUISUE aWOs £00 9ST, “aseyd ,uornnjosos, siup yo soBms juarayyIp ayp 40] sonbmuyoar warayp sperop (C66T) [a “aranayy 01 pees au Kamp passardxe you 40 porous ove Komp 41 searoyan pans uy asvars0p OD 1YaMOMp are PoIRpE|EA ‘pus podpajmourjar ‘passardxe axe rey) wed orp woys surjoay jagureg “aes WHaxsM9 s,uosied uy Sulouongur pur uo SurFurduy sssooxd sry ypis ‘apy Jo soseyd snorAaxd Woy sonsst paajosanin ypia jap 0) Buojoos se uses st Moxiad yy, “s|enpragput aroyduuoo se uroqp SumMyer ‘aidood 10} 190dsox doop w sasnodso yovordde ou, “Kirjeat yo axora s,uoszad atp SunFu9|1e4> ou ‘K\pnuoweSpnfuou pu Xijeonpeduss Zuruayst) nom ‘voTeIesoA ow woNEOLTOIIP quoaard put yudip s,uossed ayy au03sar o1 sf UTE ox,f, “IAB IUELIND Jo Modsouo sno 01 o1vpa1 spiom a4 moy Jo axnoadsansg ‘ang sv sSuTjs9y 9soqp SunepyA ‘spuoM s,uosrad ‘uy Surdpapun suorows etp Jo [oad] up JP UONeoRINUAOD SaATOAU! WOREP!TBA “AI[VSOU oy jemospypen wor SuySues eAUAUAP yA wosred ayp UT sosuodsar feUONOUID eAreFoU Suronpoid se woes sea (R61 ‘SatlOs 7p Nama "YpIe1G) VoMeOLTAUETTOD w siduroTye roy JO sty pueisrapun 03 Burjass orp soqqes uosiod ayy ,Sundax109, vo syseyduua ax, “(M024 295) uonequeno Aypoar se yons ‘Sayovoudde aanmiBoo Jo ToneruoUUD]duU jeuOTIONTONIaAO as VILNJW3G CNY SNOLNIAYRINI TVIIDOTOHDASA528 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING be given (0 the choice of appropriate outcome measures. Affect, agitation and engagement appear to be much more relevant than cognitive function, for example. The effects on stat and caregivers and the impact of individual VT require further study. Finnema et al. (2005) describe an evaluation of ‘integrated emotion-oriented care” in 16 ‘nursing home units in the Netherlands, involving 146 people with dementia, This approach inyolves elements of validation, sensory stimulation and life review (see Finnema et al, 2000), with the core aim of aiding adaptation to the consequences of the dementia to improve emotional and social functioning, Over a seven-month period the results were not dramatic but residents with mild to moderate dementia in the homes where emotion-oriented, care was implemented showed less anxiety and less dissatisfaction than those in control homtes, There were no differences attributable to emotion-oriented care for those with more advanced dementia, There was evidence that the extensive training provided for staff in the units where the intervention was implemented did make some difference to the care provided, particularly in relation to making use of knowledge about the resident's life in their care; however, the extent of difference that the training made in day-to-day care is difficult to quantify. ‘There is also a growing interest in the application of a broad range of psychotherapeutic approaches with people with dementia. Cheston (1998) and Kasl-Godley and Gatz, (2000) provide helpful reviews, illustrating the lack of outcome research in this area to date, Earlier recognition and diagnosis mean that services are now in touch with people with dementia who are cleatly aware that something is wrong, that they are not able to Function as they did previously and who may have awareness of others (perhaps their relatives) who have had dementia. Sharing the diagnosis with such individuals provides a therapeutic platform to offer assistance with adjustment and adaptation (Husband, 1999), recognizing also that symptoms of depression and anxiety are common in people with dementia (Ballard, Bannister & Oyebode, 1996). Burns er al. (2005) report a randomized controlled trial of six sessions of individual psy- chodynamic interpersonal psychotherapy, compared with treatment as usual. Although there ‘were no significant improvements following the intervention, the approach proved feasible with, and was appreciated by, people with early stage dementia. The therapy was carried ‘out in the person's home, and the therapist spent ten minutes after each session, listening to the caregiver's needs and up-dating them on progress with the therapy: there was some evidence suggesting positive benefits for caregivers of people receiving the interpersonal therapy, CCheston, Jones and Gilliard (2003) describe psychotherapeutie groups for people in the carly stages of a dementia, where the initial focus was simply: ‘what's it like when your memory isn't as good as it used to be?" Participants were encouraged to share experiences and to discuss their emotional impact, whilst the group facilitators offered reflections upon the emotional significance of these experiences within the group context. Bach group ran for ten weekly sessions. Overall, participants were significantly less depressed at the end of the group. ‘Forgetfitlness’ was the main theme of the groups, encompassing the experience of ‘memory failure, but also the pain and distress of being forgotten about, and, conversely, the desire to be forgotten about and to be able to forget about oneself. The groups engendered a sense of togetherness, with one participant saying: ‘T now ... know I am not the only one. A number of initiatives are being developed to address the support needs of people with early stage dementia, Yale (1995, 1999) provides detailed accounts of setting up andpuv Sundwoud SuyApoaut yowosdde ux jo uononpomur ay Sumoyoy ‘epTauTap pey UFOKeA Jo ano} ‘stuapisas outoy Fursanu aYata wt ArTIqow pasearout payodas (96 I) ‘}0 19 OFM ‘squvysisse Zursmau Aq asn roy sanbyuyoa Fusapos-ua[qard pure pemoravyag ajduuns Padfoaul WONUAATOIUE ays “uyRaY “SuIssexp us paumnbar dyoy Jo wmoUTe atp poonpar ‘ow. neu 2anquBo9 a1aKo8 YUL SILopisax auoy Huysanee 6 FUrApoAu Spnys airy & UL “(LEGT) 70 fa Yoag “wonUaaranuy [ECONIPPE ot Hurataoor sywopisar yplas pasedwiog SwwoUTUEEATE [oO ue TCIW Jo sfanvs uo paroxduir kaw, “syaaa QZ TOE SJaam w Shep ¢ ‘SINOY Jee PIE Om) 40] vonUaAJoiut 2xp paatsoaa ‘sdnos3 U1 SunaeuH “oUFoY SuIsMeE BUT eATAMTAP YALA aidoag ‘ounuamsSoad Sarupeat siiyys (TV) Bury Aurep Jo san tATOR axISTOIUE UP cuo4y supMSaL SHOdar (p66r) wade], Bunuwa} yim arapiaru o» pammadde Aranare “tpmoy aug 10 SecUDKUDP YL {dood snog jo mo sanp UE [HySsadonNs sem STUD :SARTAHOE AnpAraAa JO AyawEA v woddns o, spre Arowiou [ewarxa pasn (¢661) "10 #0 wossydasor “eRWaKKIOp WIEA ajdood Ur SuIIeG pag ‘Buyssarp ‘ouoiBAy Peuosied sw Yons “SITPAS a129-j1a8 o1seq UY STHOMTaAOIULE Pamos ‘sanbro -yoo) BuREeN-[IE}S [Rano| ARTA YN Bursn “(9gBT) Lose pur Koxgopy ‘o[duuexo 40] ‘SJOPUTLUAI Se spy Aroutou TeWIAHKa pure sidutord [eqIOATOU PUE TEqIDA OF Sujoupos ‘sanyasuromn se) axp oMUNIUOD AoW Se Wau “AALALIOe aM YSHON spenprarput Su‘pIns spoisdyd aq wydre asry we Supdutosg “poueay(-a1) st [PyS amp se Fundwwosd Jo faxoq omp Suronpar Aqjenpesd pue ‘aBeys Yova we ssooons Bumpreaar pue Funduroud ‘sjuauodutoo soyjous Our santanoe UMOp BuPjearg “Fuses s|ppys paxoydura seq Kase SII WE sZIOM amp JO SOP aouapusdapuy Sunoworg ‘pootw pue Zuruonoung wapuadoput JO 2oUBUAUTEUI pu uoNoUFoAd ‘(2uMIOA si “EE Jaxdey- UF poranod) soBuaqTeYD YONA mOTABYFEG oO} uONR|al UL ALE paride ti9aq oaey SayTeardde TeMOLALYOR LOA SeOE ULPLIE ONL, SAHIVOUddY GISNIOI-YNOIAVHAT (8667 “UoIseyD) .uoNLIOSE [ePOOs pue LOREATONUISIP euostad 1sureSe papaayun pue pieayun 9/3Fn.Ns or aAeY WOO Os Pynoys SUINDIA ayeIpOLMUL sou sy etn @iqeiclagoeumn st 1 EN pue “XpeBex) jeuosrod # se poorsiopumn aq ist eAIMUIP eq — [erOU AUjenUassa, S| Yom auModesauOYoed eto} 404 UOWINETE amp Kp SIsoBns worsoy. ‘paopuy wre o1f oq uous Kem oBueqo et JOUR SMupuErstapuN feMmnpy BuLAoy aay pur oyjoqués a10ut seittosaq asimoasip pu: wsaasip 0) y}noWyEp 9q ABLE SuONeUUOD jouOTIES 204M uosiad B itm BuMeoTUNUMUOD Jo Ke annoayye UE ag AeUs Buswaysy| SHUMBUKPOYOKS (8661 “vorsey) enuawop paoueape azow wil ajdoad yyIa aney pnos ,oRaderayjous4sd Su1oq, yew aor ayn Jo 199/ ou o1 pear you Pnoys eUAWAP aBeys Ape Wo d1ep Oy SNOOY a1LL, “siutvcl.oqiied Aq Aqeamtsod 4494 payenpexs uoaq sey suutweadosd yp pue ‘uuosuT pue Jomodiuio o} st tute ay, ‘SBuaauravesRdas tan 1M] aAey OF ssaasSozeo pu unWouap YiLM a[doad 10g aurN se [J9M Se “JooUE 0) spedp amp [fe JOE Powoo4Te 2Uun aos qatar “POTTAMT os{u ame suBA:SaNED ‘aUUNBIOId pasmaNUS UoTssas-Q] ¥ SIa]JO SIL 30g *.qyo A1owoUws, w aquosap KaeqruUts (yOQZ) ‘79 22 1ueZ “BUND YK wv uoTSsHsTP JO] sawrarp otf uo 2439801 aploop ou ‘Stuedionted &q poquiosap uonvjost paonpax pue yoddas enynuu tata * dno sayo> Kowa inoge SupyTRL, a4l :entaurap tyr apdoad 10} Zureout dnord ado Aqyyuow v uodas (cooz) 1eaLeday puv ary43 “ntug “sdnox8 Yoddns yons Suruuns 67s VILN3W3G CNW SNOLLNGAYLNI TYIDOTOHIASdoT of | 530 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING. psycnd praise for walking more independently. Distance walked increased and amount of assistance seven pt required decreased, with gains maintained at a four-month follow-up. Improvernents wereso depress} rapid that it is suggested they resulted from the environment having previously provided few imust let opportunities for walking, rather than from relearning Jost skills. Presumably environmental 80 forth contingencies in this nursing-home setting may have discouraged walking, with staff perhaps from thi finding it more convenient to have residents in wheelchairs, This is a good example of the Interper existence of ‘excess disabilities’, where people function ata worse level than that determined, of traun by their dementia, in response to the behaviour and attitudes oftheir caregivers, exemplifying previont Kitwwood’s (1997) concept of a ‘malignant social psychology’. Teri ¢ Efforts to increase toileting skills have been less successful. The ‘prompted voiding sivers i procedure’, described by Burgio ef al, (1988) and Schnelle ef al. (1989) has the aim of evaluate reducing incontinence but does not aim to encourage self-initiated toileting. Nursing home the fam residents are simply asked on a regular schedule, say hourly, whether they wish to use the There w toilet and praised for using the toilet and remaining dry. Results have been so dramatic that the care the intervention should, again, be considered as a change in environmental contingency, later for rather than a releaming procedure. However, self- initiated toileting became less frequent ond ada in the later study and, unfortunately, when the research team leave, staff seem to prefer to behavio change residents when they become incontinent, rather than continue with this preventative trol, wi approach (Schnelle et af, 1993), suggesting that contingencies for staff also need to be strategi¢ carefully considered (Burgio & Burgio, 1990). Continence requires a number of different ‘person skills — finding the toilet, recognizing it, adjusting clothing and so on — and is affected in older people by a number of physical factors. Ouslandet ef al. (2005) and Schnelle et al (2002) report evaluations of an approach combining prompted voiding with individualized of depre physical exercise, aiming to increase strength and endurance; improvements in continence also imj and fitness were noted but Schnelle er al. (2002) conclude that ‘fundamental changes’ betweer. would be needed in the staffing of most nursing homes to implement such an approach tially ab fully. Prompted voiding appears to have some effect on faecal incontinence (Ouslander and acti: et al,, 1996) but was not effective in reducing nocturnal urinary incontinence (Ouslander approac et al., 2001). and can ‘Some work hus been reported aiming to enhance orientation around a ward or care home, through the use of training and/or use of signposts and other orientation aids (e.g. Hanley, and inca 1981; Hanley, McGuire & Boyd, 1981; Lam & Woods, 1986; McGilton, Rivera & Dawson, with an, 2003; Reeve & Ivison, 1985). These approaches have at times been included in evaluations mood at of 24-hour reality orientation (see below). Results have generally been promising, with regardit| relatively simple training procedures, using signs and other landmarks in the environment, includec being sufficient to increase the person's ability to find target locations, in what are often asimilal quite complex environments. 2006). In relj people Mood function aweek Some consideration has been given to the applicability of cognitive-behavioural therapy ‘Tranel (CBT) with people with dementia with lowered mood (Teri & Gallagher-Thompson, 1991; with red] ‘Thompson ef al, 1990) although the evidence-base is not yet strong. Preliminary reports tests of of CBT with groups of people with dementia (Kipling, Bailey & Charlesworth, 1999) and (EMR). with individuals (Husband, 1999; Scholey & Woods, 2003) demonstrate the feasibility of is sugge| this approach, at least in early stage dementia, In Scholey and Woods (2003) case-series of its suced‘Azouraur jinpeooad wo stow soqfar ‘sdnor ajosnuu jo Supeepar pur Sussu9) aatssooons sy nym “VONexejar Jo 1WI9} smIp ZuMBray se ranaq papuodsox dnors yyy axp TEM porsoslans sy a] ‘sanbyuyoa) uonexerar feuEeuN ut pauien sem ApMs sq) ut dns jonvoo aM, “CUWa) uonexeyas spasau oalssarond ut Fuperen Suratooa7 dnoxs op ut wonouny aAnTUsod Jo $189) aos Uo sitawaxouurt pure suto]qoid Jeanoeyag pue AorxuR pores-UeIONHT|D paonpor yar ‘sBurpuy asoup povroddns sey qouar ‘swuoned pe SuAjoany ‘LOY e Hoar (6661) TURAL, pub uosiopuy “KNg ‘cnosd worssnos)p e papuane swwarted JosIUO;) “sipuoU damp IOF 904 e soup sau sdno18 uonexeyaz Fuipuotie asouy us uOReofpaur Serds9qs Jo sn S89] puw uo, [eanoyaeyaq jo sfumnex panciduu paysodar (296 | ‘OTeABSOK 79 HapIIAA) ENUTALUA yA a dood quis sonbiuyos) uorjexrjar jo siooyjo ayn to Apms Sucreauord & “Ararxue of WoHEpaT UY “(900% “qv 10 sepuejsng) daays uo yoedury ou pe Yeaquoo auoY Susu e UT ouTTeNTord reps & ayo ‘asenuo9 Uf "(coog “72 22 AunQe~\) WoISsexdap paonpad ‘ures ‘pue dooqs poaoidwr popnjauy ua samoaino ‘arnsodxe 14iiep pur asiazexo sUINAEp pasearou pure ‘ouarRAy doays TuypmwFor pt Joarasvo oup 10s ao1Ape YM MoNDUNfeD Uy “StUOHoUNY JeoIsAy poaoidus osTe pur poour suone povsaidap ur suononpar utede atom axon (C0OZ “70 49 UA],) auUUUELBOId asfoz0xa WBA, suosm pauguo; (Gogg “7 47 Ha) eNuEUFap YUM Uostad ot 404 ayI{ Jo AnfENb pasrarour pu shoyu swe}qord moraeyeq paonpar pus Yapinq pue worssaidap ronrfame> poonpar apnyouT sam0> aay =O ‘Buuren sword ym sjeuorssajord auvorpjeay Jo aftues e q paroayfap 9q WED pur “(S007 “70 42 LAL) yovordde sjooo1nrg apmeas, arp se paquosep Kttadar arout st yoRordde spud! SIYL “Yowordds ax Jo woWfe Kay ¥ S] uioUMTONTAtIE kepAiaaa S,costod aq) 1 SonEANTe puke ‘opae STIpis Jo uonezi[ez2u08 ojqeua oF puw donatud Uossas-uoasstag repNBas asnsuo o} 9Ige AqyeR pron usjod st oy ‘ioaifaseo oy} Jo wtattasjOaNT aANO® aU, siWOURwAN angse O78 atp UEAAKIOG ssouarayip ou (pias ‘dn-moljoj yuoU-Kis 1e poUrEIUTENE arom suIeT asO4{, ‘panoadiur ospe poour sAITom9 “A[SunsarayUT “suOTNPUGD [ONTOS om ay TEA paredu1od ‘uorssasdap Jo ‘Sfeao| peonpex WIA payeIDOSse arom SMORUAAIU! [eINOFAEYEG oy os] “UoNeDo]TE yeU ~yan 0} PUTTG Ino pL atom sjuoUISsassy “SuONEPLOD WHOUNEAN sno} olf 01 parvorTE Aquropues uoog BurAey Xpmys oy payolduoo speép .soaianeo snyd eHuoWa \pwvs uosied, — | omy-Aquanag ‘dros’ jonuoo Ist SuNEM v see a1aq) ‘WONppe UT “perdope Suraq saierens [rmoraeyeq Jo Bu1ajos weygord ay!seds ow ing ‘parayo Suraq woddns pue aazape yprAn*, [03 -uoo 249 pods), & pareyo uoRIpuOD pm y “eNUATEP Yala UOSad ayy Jo sMOLeLOQ uorssaidap, oyzods uo Buisnooy “yovoudde Surajos-wajgoud ajqmxoy stow v poidope puo -998 OJ, INOIARYAQ SuPuayeyo IuFeuewt soy sarFayens se yom su ‘Saajosuioyp TOF JOWey pur ‘erjuawep Yim wosied amp soy sywoAe quesvald dofaasp pum AJNuapr 0} JaAtHaIND aug Buyyoue) poajoaut jsxy aq, UOMPUOD Yore ur sUOTSsOs smOY-ou0 APFOON OUTIL a19M AUT, ayqissod se 12] se popnjour Suioq eRUOWEP YpLA UOSrod aU HMIA “ToAMRaswD AqOEY op ius Apseurad Zapjiom paajoaur suonmontow ay, “(L661 “PP 42 Ua].) LY e UE porenyeas uwe9q sey YoTyn ‘enUTUHDP YM osied ay Jo poour passesdep au) JuuirumUs UE s19AIT saws Aypurey Fuyajoaur yseordde pemoraeyog a1out v aquosep (667) OIOWON pu LOI, ‘Texvom auuvsaq A[snorard Te® padres pey rerp sayayens Fuidoo ayy se 4[noyyp oxow oumooq siuAe oAeUNEN JO soprouaur ised jeu pajou ose sem yr pue ‘KueUT 40y JUaUTad arom sonst [oUossadsoVUT ssaussajadoy Jo asuos w pute jaNuoo Jo sso} ‘Kutanoasut Jo sBuyfaoy a1om Sosvo soy) WOM SuiGroua sowoy) aip isFuoUry "MoneAyoe eAnoMeyaq HO siseuuE cIOW pus “yWO] Os pur szepururer pue sydtword Jo asn ‘uonnadar aru yy ‘suonesdepe owios 0} pear isnut matearedatt oanmBoa Jo aauasard ayy youtor Jo uotyearasord juoredde oy) HuOsY stHaIS YoBoIdde sep JO sisEq oANIUFOD M4, ‘spoon, 27 “Covaued ,speapiarpay sapeaut yeyp Yououdde onssnstuy ue plone oy paoU v SE women: oroup put ‘sroqurotn zaq0 Aq paste 8ur9q am sjenpLATpur UFeUAd 10} StO!NBIONIOD OLIN ‘avy IoIp SiusAd Jf UoALd oq ued woddns ayeLidordde asnsua oF “Me oduiy St so1sOIS:Y ABET oy aouroyyud quedistmd Jo ssouareme “Sumas dro’ e uy ApeInoIIEg “eNUaRUAP JO gaiBap ayeiapow Buys 8uy ot} ©; pir v yp 91doad soy ayouidordde sr yovorddde sy, “Saqiourou! ons ya parwyoosse Aqjenba axe tuted 10 ssanszp Aue wreqUoD 0} {LOA [ENDIALpE UE 32xFOM ay TOIT 10 “SraquIeNT JoXO PuE sapra| dnos# ay woxy o[qpjieae st voddns ynq ‘ailiaura Avmn sarsourow pes “asaydsoune ‘2ansod ‘poxvyare tto sr snoog 2th pur paSemoou Aypeoytoods you sy soyoureU Jo UOTIENTEAS ‘pasn ptonboly axe sidword pue sawoy) ‘soousyiodxe 10 sitiane aytoads ueyp seuowrent Joroua8 aiotw apnfouy Kew umoy aaxy 10 pammyonns aq Sow ‘pasta dnos# 40 yenprarptt ‘2q feat 1] “WountRUa\US pue amnseayd Suipiaosd puv uonwZtTeI90s pe YoreoruTUATUTOS ‘ys oqdoad| ‘pasarou SurpnjoU ‘s[eo8 Jo Alotea w Burner se weds St pueq soyyo axp to, aoUDOSHUNDL, v saompd ‘pt ee VILN3W3G CNY SNOILNIAYSINI TYDIDOTOHDASE ONIDV JCa | 534 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING. PSYCHOLOGIC reiminiscence-type work, such as trips and activities that related to the person’s interests and enhanced wellbe: experiences, and the creation of an environment persoualized and individualized according, | twcognitive chan to the person’s own style and preferences. Residents were reported to have shown increased in people with sociability, decreased aggression and less demanding behaviour following the implemen- Randomized cf tation of this individualized approach. Staff also responded positively, recognizing more inhibitorsarenow, of the personhood of each individual. This study illustrates the value of life histories as a home-based stim ‘major influence in care planning, helping staff see the person in the context of their lifespan Feport improved following an eigh evaluated the effe, i on people with ce and so improving the quality of their interactions Cognitive Stimul. and affective bene There does seem ‘The definition of ‘cognitive stimulation’ proposed by Clare and Woods (2004) would appear associated with ev to encompass an evidence base that was accumulating long before this term began to be used. The evidence de in the dementia care field (Woods, 2002). This relates to evaluations of reality orientation | in maintaining co (RO) (Holden & Woods, 1995), a long-established psychosocial approach that has been people with mild used with older people with dementia for 50 years. It includes two main aspects: 24-hour Although initially RO, which involves a number of changes to the environment, with clear signposting of are learned, more, Jocations around the ward or home, extensive use of notices and other memory aids, and a | tended to support f cognitive stimulati and so reports of € orientation fell out in a mechanical, is 1989; Holden & ¥\ flexibility of appre interventions, althn day-to-day Fanctio required. consistent approach by all staff in interacting with the person with dementia; and, particularly relevant to consideration of cognitive stimulation, small, structured group sessions, meeting i regularly, often several times a week for half an hour or so. A wide variety of activities and | materials are used to engage the participants with their surroundings, to maintain contact | with the wider world and to provide cognitive stimulation. A typical session would go over basic information (such as names of those in the group, day, date, time and place), discuss | ‘a current relevant theme of interest, peshaps play a number or naming game and finish with refreshments. Throughout there would be a tangible focus: a whiteboard for the current information; pictares or objects appropriate to the theme; personal diaries and notebooks for those able to record information for later use. | "There is a strong evidence base in relation to the RO and cognitive stimulation approaches. | | Spector etal, (2000) present a systematic review and meta-analysis ofthe RO literature, | | focusing on RO sessions, Six studies, including total of 125 patients with dementia, were | | ' Cognitive Trait Cognitive training involves guided pt of cognitive functis ular “exercise” has ‘and that such impre tent, although this * cized (Bird, 2000). people with mitd c¢ modest task-specifi of gains (Rapp, Bi Marcoen & Goo: tia drew very clear] included; there was a significant effect of RO on both cognitive function and behavioural function. Spector et al. (2001) report the development of a cognitive stimulation programme from this review, comprising elements of RO and reminiscence, drawn from studies showing the most positive outcomes and comprising a range of activities encouraging cognitive activity in a social context (Spector ef al., 2006). Spector er al. (2003) report an RCT of, this programme with 201 older people with mild to moderate dementia, drawn from 23 care homes and day centres, who were randomized to standard care or to receive 14 bi-weekly sessions of the cognitive stimulation intervention. There were significant improvements in. ‘cognitive function and in self-reported quality of life for those participating. The size of the effect on cognition proved comparable to those reported in published studies on the most frequently used medications for people with Alzheimer’s disease (the acetylcholinesterase inhibitors). Evidence is provided for the cost-effectiveness of this approach (Knapp er at, 2006) with preliminary data suggesting that weekly sessions maintain the benefits for at approach, arguing t least six months (Orrell ef af, 2005). The improvements in quality of life appear to be '_—-—& Reever, 1982). R| mediated by the improvements in cognition (Woods ef af,, 2006). This suggests that the & Woods, 2007) als|tuo syuowosordum soonpoad Seruyen aanttoo yerp aoueptAd ow PUNY Os|e (Z00Z ‘SPOOAL 7 auaig) $g002 "7 J2 ale) vo SAP Hy S]_DY Jo SmaqAay auRIYDOD WaVY “(GL YOAIY 3 jung, yh) wontensnyy pur uoIssardap asrarour oF Kuo pgery seat W 1eyp Suunre "yowosdde ue yons Jo yjiquondde por sigouaq oy moge stoySsMSUOD aANesoU IPO}D AIDA MOUP VN -vouiop (ja oldoad 20g Suruyan aaniion Jo SoIpmIs AU, “(ZG6I “SUESS0OD 7 UDODMEYY ‘aoyfomyson ‘9861 “@BRANSOR 7 IH “HAIPUS {ZOO "USA 3 Soudaig ‘ddey) stmes Jo sourusquret pay 19a pue voNRZyeToTas Ot Inq sWoWsAordwT syroads-yseI Isapout parystowiep a4vy ‘pazuofares pu pouyap Aysnoua ‘aurjaap aantusoo plus qm aydoad sapjo pur ajdoad sapyo Ampreay opt pasn soysvarcdde Fupuren aanuso-> “(O00 ‘PAtA) Paz [euOsTed amp Jo Junodde saqTI WEP BoMOWUNT LOPE quem jaudroqur ¢ em pautquioo exw AdesopoyoAsd pur ABojoyodsd pemoyweyjaq “ ou “ay oSeas ‘annus snow! “(ho07) Apoog. ‘uorenyiqeear oxnudoo -ysnosdde pasnooy -ontudoo Jo puny juasoyp & Jo wamdojacap Wed atN OF paInqusTuOD Sey Yel SIO] amp sary Jo Yous 4 Jo au0 st sidy, “eAEEWEP yjLe apdoad Toy utes aaryusoo Jo aner ayy Woddns you saop -uyeg) sa0rss< auapina jo douyy2q [[eIOA0 IH nq suipuy aantsod ovos oder sarpmys SuuteEN aALTUBOD pasegrzoindiu Sulyios apy yeas ath O% poZyIoUae 94 pInoD Saueyo Yons Fay yay ou aonge: awajoun st jf yBnoupye ‘souvuoprad dnasd Josjuo9 6) porediwoo sware payee uy sures Hu yeuprarpur :sye “yex1suoulap Syooganbeyo v Surouyjng pue oseypind w Loy aBueyo ZupyeU se Yas SAse UE -aas Buouw as siuedionred pouran (pg9z) “72 J2 ufarstamao7, “pearouo sey Surumes JO Sndop YI Se SSE fend 3p uode ayf-Tea1 Jo sonopeur Iugdope spxesor pusn sUtOs|am v ‘Ianaaoy| ‘KUBY “21 KUpAIOA “stanct ‘g007 4 s,uostad oy 0} siyy Jo sounasTar apqissod ay) ssourwy 07 Wdwione amy weg Affeardéd sem “Suppeor ‘vont aieyp éforeumroja7 “sear awos wr paaartpe oq Aur siuotUonosduay oyfoods-BuyarEn wey “109 ap Jo au “qoys “juauireduut jo soimseaun pastpmpues Uo stoayjo Aue spy BurUTE AAT BOD wep ENS saspuoxe pozil -uoulap 0} MOUgLp A194 SE 1¢ oTRp “[exOUN UT ‘stuo| gard [eo‘Rojopompout o1 K[2[os parnqune f9q uvo Siar aanwuoo jo sioaya THeOylUsIS ayexIsUOUAD O1 ammysey pwardsepia emp WIP ‘Ajaggqun S19 ynq suONEARAy [worROFOpoTpauT snorauanu oy Dofgns ase wae sip UE SIPS STAUOY Jo sasop [eumndo Sutaraoas |e ase oy syuedrot sed papaya Ayjensn aan Soxpnys ywa091 BOW “(6661 “HON F asval,\ 3C1) mora stip Jo] woddns atmos aptAasd pip (STUDY) SIONAL asesarsouTOyo| ATOR wowed 9} ‘asvosip 5,100 sapour yanoyl as VILNIW30 ONY SNOLNIAYRINI TVIISOTOHDASE ONHDY JO A}538 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING a fuller discussion of this approach, with examples and sample intervention protocols, see Clare (2007). ‘There is a strong rationale for focusing on cognition in early stage AD; indeed one can argue that cognition should always be considered. While cognitive impairments and particularly memory impairments are a defining feature, the problems are not global and a profile of sirengihs and limitations can be identified. Neuropsychological models of memory systems (Squire & Knowlton, 1995) indicate that episodic memory is severely impaired while many other aspects of memory, such as procedural memory, are relatively preserved (for a fuller discussion see Chapter 11, this volume). Thus, we can try to make use of the preserved aspects of functioning, and we can ensure that we place only Limited demands ‘on the impaired aspects. Similarly, in terms of memory processes, encoding is particularly severely affected, and this indicates that we need to focus on supporting effective encoding if new information is to be acquired. There is good evidence for cognitive plasticity in early- stage AD (Rernéndez-Ballesteros, Zamarvon & Tarraga, 2005) and emerging evidence for a degree of underlying neural plasticity (Sperling ef al., 2003; Parienté er al., 2005). People with carly stage AD can adapt their behaviour (Burgess et al., 1992), learn ot relearn skills and procedures (Salmon, Heindel & Butters, 1992) and retain new verbal information (Little er al., 1986). However, they require greater support than other learners in order to demonstrate these capacities (Backman, 1992) and this is one way in which cognitive rehabilitation can help. Cognitive rehabilitation interventions aim to identify and tackle the difficulties that are ‘most relevant to people with dementia and their family members or other supporters, taking into account the person's current level of functioning. A key element in this approach is the collaborative identification of goals and needs, reflecting the impact of cognitive changes on daily life and wellbeing, which are then addressed directly in the real-life context in order to improve functioning. Individual interventions are then designed to address these goals. Interventions generally fail into one of three categories —restoration, compensation ot environmental modification, Aims may be to make the most of remaining memory abilities orenhance or maintain performance of everyday activities (for example, helping the person to remember important information so as to be able to continue with an enjoyed activity), to develop the use of compensatory aids and strategies in order to reduce demands on memory (for example introducing a calendar so the person can find out what day it is), or to alter the sucroundings so as to better support everyday functioning, ‘Where the aim is to make the most of remaining memory abilities, a number of principles can be applied to assist with taking in and retaining information. These include the provision of extra support at encoding and retrieval, for example by means of appropriate cues, mnemonics, or spaced retrieval (Camp ef al, 2000; Hill et al., 1987; Riley & Heaton, 2000), and encouraging rich and effortful processing of information during encoding, for example through semantic elaboration, multi-modal encoding or subject-performed tasks (Bird & Kinsella, 1996; Bird & Luszcz, 1991, 193; Hutton ef al., 1996). While errorless learning, or the reduction of errors during learning, can produce good results, the most recent evidence finds no differences between errorless and errorful methods, suggesting that leaming may be achieved through a variety of means (Dunn & Clare, in press). The application of these methods to address memory difficulties in early stage AD is illustrated by Clare e7 al, (1999, 2000, 2001, 2002), while Bird (2001) describes their application in addressing behavioural problems. the relative pr be used to ao assist in estab is evidence thd living Josephs basic skills sug The use of memory fanct including, sim dementia itma efficient. Intro is given for le social engager can make it ee 2003). The Int while the avai benefit for pec technology of et al., 2004) Alongside a tation includes with a range ¢ course import be valuable to. importantly, w ‘igsues will em ments. Theref Finally, the pe family carers ‘There is no. ‘The whole poi of each persor engage in am members, and CONCLUS, ‘There is now with people ¥ approaches tc, there is great such approac of a psychold here.2504 paquosap a1am Suifioulo squouoyo Koxf owsog NO] 94 HM Yuordde yeorRoqoNacsd & Jo pouDsso olf “LIW 44 voREATEAD ue Jo raxaRf-avens ow 1 AoW weHR os SayoBodde Yous ieyord 01 Hupyeas Urey SE ywar y 1 OTOL, “SsouOANOOJD so Uy war YwOUs $4 OD pov menos Aifln amt ‘sao apes eyutae ss] a4ny oI “woneorpou Soyouoadde panewiafy “suondaaroqus poroyooruagdaon, Ut sro] Te 40 “euarwA qu aydoad Wise Fuppion o1 Sayoeosdde yworFojoy>Ksd uy o70Joq LON LY WaTOHUT saWaIH MOU St HOM SNOISNTINOD -spaau pus uonuans sf) 09 astiodser onsyjoq, purv eananuysto9 & Jago 01 Pur “srOqugNT ‘yur oxy pure eawonrap aanq oye ofdood yes Kea yneAdqat pre pysamueat v ul aes fy wsiBojoupisd earuo axa 40) AyumIoddo anstea.o B SIay4O 1 SPuanbasuo,) “Wosiad pra Jo spoou aujtoads ays J20u 03 pasoye Apenprazput st wey st wozdde sy Jo Wutod TOU Aa, “yonuan sammy donenyiqeyst axnuitoo # SuONpHOD £0} YeULL0§ 19aU09 OLFUTS OW SF SNL, “qovoudde sp 30 stfouog amy oztustxmu 0) siayoddns 20uH0 20 srasv9 Aqrunes tym 0% 07 mrEOdk sue paroprsu0d 29 O1 Speed HxaIUOD [B08 S,uostod ayy IfEUL -yasttodsax [euoNOWa Ho sn90y B IPNIUE PInoys uOKMALTIqeGa IALTUsOD “axogoAeLL, “SWI “edu Jo 9s daussa.nsp £yqyssod pure ynouysp & Ko sMOoy at Jo HSI su BsoUT [TA SONSSE teuonouta yeqn meso sour st ‘uorTTiqeHoH Banoo wy Fuyzsue uoye “ Joyo Jo requ G SaPHION! wow “iiqeqau aanruSoo 0} ypeouddn parexsoyay Me ‘somnoup AZouraus | wonueHe apIssuelV one “19 ryonmeg) urewop sip wt uonroyddy aarear9 205 sonranroddo Suumos8 suayso ASojouyer Tuidoyonag -(ssaud ui und) 3p Sprejaoy ‘247[) StHa|coxd AzowsoKH YL a[dood 2ep yyeUeM tar Jo 29 ue woneoUnTNOD [PAKI-9 U) UaLOGU! sprover THBLP JO AaTqeIEAE 2h OTE “(e002 "79 12 wewseo4g) uorFeALOFME |ryosn Suypuy Jo Kea aprosd wro rouseyey aL, “LOOT “yp wo nay) Stoquual Styusey YORIUOD 01 BLIP HAM osrad Kf 40] Jo}SEO WE DYE UWS souorfd 2140 (0661 ‘seaimog) uoneszoAu0D J0§ SIdtword sv Buyos“oUUESE (wos Tityurvu 0} day, uv SqTEIs ATOWOU TO S¥Oq AIOUIO "I asm O SuxmWDT 40) OnE St jioddns ayeudoudde papiaoud [ryssaoons aq wro pre Axoutsut afou B Bwyouponuy W!eyPLS Grourweyy axpu pus asauy dope o1 sarBarexis Susix@ wo pling orsjqissod oq Aware eHUaUAP anim vosiod oyp 30g] “Sisy, Suiddoys 10 srepuoye> ‘saxrmyp su yons spre ajdauss Fuypafout ‘Hoqpoue 10 uy uo ut sper KsoUAW Asn sm JO ISO OAT AepATox9 wo Burwonouny Arowdgus ppasteduay jo roedun ayy Joy aresuediaroo oy djay ura spre Alowrout yourorxo Jo 280 UL (q661 “Kut. 9 Pal “dure-9) JJos9uo paay 01 woods wv Buysn sv qos SIPS 91EA jo wonerorsar oy 04 pare ag weo soyvordde weymurs pu (E661 “7219 wossyasop) MMT ‘jvop go santanse woddas uo Tuvonouny AroMaAt Empaooxd or woe Wey) 2ouDPIA> St ‘ueity, Ino popes kypenpers aq weo sand 2x Yon aye “doueuLLOpsod Huryst|qeIse wT ISS tueo sono Jo worstAaid “O6GI “72 19 YOM £9661 PI[PSUER 7 Pale) 10eH9 Pood 01 pasn oa ‘eur syse) pouutoyrad-roolqns “wreae ara} “K1owradu yeanpeoo.d Jo wonearasard oate|ay oth tio Buipytnq asjonut sarAnae AepKroxe Jo aoteunoprad cwenuNTL 70 eowwqu oF sxdnaNY oes VILN3WIG CNV SNOLLNAAYRINI TYIIDOTOHDASA uy woseoyjdée ay porensnqt st qi ous, “(ssand ur * upsoBBns ‘spor ysout ay “san SSO] YAN | syse1 pautuiogtad oy “Buspooue 3c sur 79 Koyry “sano oyendosdd vorsioid op opr soqdinurid jo aq a 23118 01.30 (8) ‘Arourgur wo spur on (Aazarioe pak uosiad ou Std sommegr Krourow so uonestisduton sau Ssappe or uy rxaquod afte soflueyo oxntuse amp st ypeordde s upyr ‘stouoddr ane vey) SANINOYL 2anTUBoo yoryar Jepio ur steams ‘uoWeNUIOFUT peqe umajar 40 wiea| ardoag “(co0e “T 0} auapisa Sur ~Apea ur Ayonsey Suypooua aansay Apejnonsed st 3t, spucwiop porray 219 Jo osn ax! Poazasaud Konan posyeduir Apauans Kzoutout jo sj9p9} ® pur jeqo/s 30u Pur syousredua| 240 paaput “c1y| 22s ‘sjoaoyoud ud ONIDY 40 AD4540 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING OT i PSYCHO| ‘The need for approaches tailored (o the individual must be recognized. This is evident in the work on cognitive rehabilitation and also in relation to multisensory stimulation, where Van Weert et al. (2005) describe the development of individualized ‘snoezelea’ care-plans, No single intervention will be appropriate for every person with dementia, Skills need to be developed in assessing the person’s profile of strengths and abilities, preferences and interests, life story and values, in order to tailor the intervention to the individual, Involvement of family caregivers in interventions wherever possible is also recognized as essential. This is seen in cognitive stimulation programmes delivered in the person’s home (Onder ef al,, 2005) and in behavioural programmes for depression, sleep disturbance, etc, (McCurry ef al, 2005; Teri et al., 1997, 2005). Increasingly, there is less separation between interventions for caregivers and interventions for people with dementia. For example, Gruff et al. (2006) report an RCT of a 10-session occupational therapy intervention, carried out in the person’s home, involving the family caregiver, with people with mild to moderate dementia. The intervention involved a number of components: goal setting, compensatory ‘and environmental strategies, aimed at improving activities of daily living, training for the caregiver, using cognitive and behavioural interventions, enhancing problem-solving and coping strategies, training the caregiver to supervise the person with dementia effectively, Results showed improvement (compared with no-treatment control group) on activities of daily living, with the person with dementia requiring less assistance following the interven- tion, caregiver sense of competence, and an assessment of motor and process skills. Benefits were maintained at six-week follow-up. The intervention appears to include elements of cognitive rehabilitation and taining for caregivers, similar to the approach of Teri et al. (2005). The emphasis here is again on a joint approach. The joint reminiscence groups described by Gibson (2004) can also be seen as an intervention targeting both the caregiver and the person with dementia, end, importantly, thei relationship. Related to the involvement of fumily caregivers is the importance of evaluating effects ‘on family caregivers and on staff working with the person with dementia, The effectiveness of interventions in care homes depends fundamentally on staff input and staff attitudes (see Chapter 17, this volume) and their response also needs to be monitored carefully. This has been an issue, for example, in the prompted voiding programmes devised by Schnelle et al, (2002). Similarly, maintaining changes in the home setting will usually depend on input from family caregivers. Studies such as that reported by Teri et al. (1997), where depression was reduced both for the people with dementia and the caregivers are especially encouraging in this respect. ‘What is the mechanism for the changes that are associated with the improvements noted previously with a wide range of interventions? The concept of excess disability is a good starting point; people with dementia are often capable of functioning at a higher level, given the appropriate conditions of support and encouragement in their care environment. This is demonstrated in a number of the skills training studies described previously (such as Burgio eal, 1986; Tappen, 1994). Approaches that focus on the person’s strengths, or which increase a sense of pleasure or mastery, or reduce anxiety that interferes with performance, may all reduce excess disability. As methods of analysing brain function, such as fMRI, become applied to monitoring the effects of such interventions, it will be of interest to see what the neural correlates may be. Potentially, these may lead to a new wave of targeted approaches. Itis important to establish realistic, attainable goats for work in this area. The dementias provide many challenges, with a natural history of decline, 2 high risk of physical health problem achieved =a and/or informat| helpful rather thi icis in gg be built prevent, person w vidual to content. There the value however will ther come ak dementis with der of care ft REFERI Backman, except Baker, R.. stimal Baler, R. on old Ballard, ( Journ Ballard, C Intern, Baruch, J reasst, Beck, Cy on pet 13-88, Beck, Cut impail Bird Mg Cogn, Press, Bind, M. ment] Bird, M. Aging| Bird, M, ies“02-806 ‘e1 “WBojoysisidomay poucauactes pun po2}ay2 fo pousnoy “280251 sou aray we tea! pan pu “Fuysse0oud yo undp “Araytoads Ruypoowa (T661) W248 BWP “os-sh ‘IT Study pu Giojoyny “oratap 2quas wy sys JO 2a and UNa}-BUOrL (96GT) “O “POSH WIA PHEL SL _26E “TT wounuyqoyeypoo!Sojoyatsdaurey Gap IA [oot PUT FRNA -agdxo senuowap ul inoynatjaq aandepe Jo Te9ar pono pare saqynayyED wsnOLAet oR (7002) A "PAE “proyxg ‘S84 {fatsiannup plogxo “{AI@ON SV 79 MEMDER “T-TH( CLASP) AY PLO MI uoLPH ADDY aaNEWED ‘iu eauauop ursyoyap axgnuBos uiox Sustze surayqou 105 uormLqeYaH Te}SOsOUDKS (OO) HY PHEL Ze-9T1 (Oop yorwasay Stasany “Sjuoprsos awsoy Susnu pasgeduT, Aonryuo9 ny soraeyag Humssaip Fmanxdmy (2667) 7 19 “O'S "HOA “Ad POM "AI WPL BEL 7 ENG anton 40, “O-bL6 LE i21908 SOHUDLIO uoauowy Jo oumog wosrertoL0 Kiywoizosioay;>asroapy (6861) SSOUOT CT HOMEHL "LF UTR pany sie L81S “(lddng)Tp souaruaBoyatig ppuoumuayyy ay? we (Lz) WouneaN Sup pure ~oqoar d pat (49) sumatioud Sema anpteoa pauiquioa Jo Tord feoIBO OOK (6661) NBO "1'25991A 90 ‘6-1 ST ‘S12pA0sIC] pasoIosSY puo asnasigy .auiay2] -KpMIs payjonuo>-oqeaxed paerwopwEL caxwastp 5,18 te fastasicy xouroueyy UE voTUaa:9|UE aAnrUBOD (1902) "SA “SPUOC °fa “WUDSEA “N'A ‘SAE Zy-VE 'b kusEnyaksg pn}908 Jo PrusnOp pouDDLatHy eompave ys, olenjuos oqtias waysisiad Jo yuouaran yertaurusds (3661) 12 19 80d “OW "ZT “USD “aIsa"p A ‘SUS 79 AOHLAL sowoyog © Myo “stuouvoyduay jmona}D pun pojong ‘Sassoon. Aousnsunciay pur SW9SY (RET) ‘D'd “UELO|OD ‘outmu000 2104 AON NUUCWWOD 79 WOUON “AVAL SIOPIONIC Parlay pun asvasiq ‘99-LSE "61 sytouujoyeyy fia aun ayn sof aainosay Sper 0 fg fo $807 U1 (9861) “D “FHOPSIL °C. OULD yoo Tig*8Z Y818ojomua!92) ‘siapuostp pamax pue asiostp SoMNoNATY IM sitouR bo syoqye sun UoNEIMUNS poanpaL Y (88GE) “D "PLINY 7 "A “HE "D ‘wou “wil ARI} p buy fo UOISRUDTEED “80S 9 ATLAS WUE GOO "P BUSS AMEIGLT amanjpog ayy, (moran BUUREN) eAUALLSP IM]NOSEA pUP AswasIP s.LoUTAY|Y BBUIs-Kys"9 45 $Sanuaiy aannuiioa pw uorTe WEEE BANTUBO.) (E002) 19 2 “Ga “AOO.-ZIUOW “A ‘SOoRK "1 “SHEED seysoqony ‘su0g 7 AAT yor Keiqy suemppor TB (asrAay auRsYDO) MULTE FENOSKA pue ASUDSIP S FUN aiets dquo Joy BuuIesy atwuRoa pub voNEN|eUDI aan (LOZ) “E “SPOOF “1. “SID Top-S8E “PT wonvnniqniay pwaifyjoyaisdomay ‘aysou 8 asKOsI SroUTIDYAY 28S -Auiee rps ai doad 10) vormnyiapyar axniusos pur Suu OxnwBO (HOUR) “LA 'SPOOAK “T3121 “oop one 9-12 "92 “Bep0H souaosyuee isdamnayy uiouniodssy puo yo2n.y fo jousney wogeyyrgeyet aansifoo 30 240290 04 diystoe “jos tastomp suoutayTy at4s-Km09 wr SsouaALY (F002) 79 19 °D ‘sam. “Y's “UOSTEAA “T3119 porsodsns 1 ‘Lp- 896 "91 KSojoypésdaanayy “aseasip ssauNaTFy ' aBeas-A1se9 UF suowejaosse auxeu-aony yo Bumumea|>y (2002) 712 12 NAMED “YE “UOS.A\ "1 "3719 -aid sonowa ‘ELLY ' {{{ wonenngoyey pworBojoyassdasnay fo anssy woads v coyuauuact us wommngsqnyey aHmd2 , fo pusnog } -Apms osva ofits v :odA) zatwrouzyy Jo wvauiap Apia ut wonnonraque oMerTEqEYSA OANFOO wv Suoy]0y sted juouryean Jo saueUo;aTERT UIIDy-uOr] ({OZ) 10 70 °D ‘TaN “Ye UOSTAA “TSE ‘Or-TEL "TE “Mojoyrksdamnoy, pewwoniadg pun poonnys Jo poumer “yovordde Suumey ssaftous we Zosb9sip s,rauu}24zTy KO ur swaigord Kiouraut Kepksone ypyas SuruOAzaNy (002) 10 12 °D ‘TALES “We “UOSTA TBD ‘Op-LE '§ ‘asvonnay “asvasip § Fowxzry AIse9 ut ‘suonproosse atteu-2004 Jo Buqumay ssoptong (6661) Wf SO8POH B"N'UAAIT "WA UOSTLAA TAI pinawiag oUaUTap aBes-AUR Ut KUEP! [BOOS pases Surdojanap Jo rnd ayy -pBuass axt9o[1o> (8503d Uw) A UND 7y “f'SPLE|MOY “7 “AMID wopuoy ‘st “«Boj0u} ‘sssaig ABojouDAs “vuuauiag Wat apdoag pu uopDsygoy2y [PorBojoyKsdamnay (LOD) “TBI onsmboe evs VLLNaWIG GNW SNOLLN3AYSINI TY3IDO TOHDASA ONHOV 44544 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING Oy ! i PSYCHOLOGICA Gaebler, FLC. & Hemsley, DR. (1991) The assessment and short-term manipulation of affect in the severely demented. Behavioural Psychotherapy, 19, 145-56. Gatland, J, (1994) What splendonr, it all coheres:life-review therapy with older people, in Reminis- cence Reviewed, (ed. J. Borat). Open University Press, Buckingham, pp. 21-34 Gibson, F. (1994) What ean remtiniseence contribute to people with dementia? In Reminiscence Reviewed: Evaluations, Achievenients, Perspectives, (ed. J. Borat). Open University Press, Buck- ingham, pp. 46-60, Gibson, F. (2004) The Past in the Present: using Reminiscence in Health and social care. Health Professions Press, Baltimore. Goddaes, J. & Abraham, LL. (1994) Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment, Archives of Psychiatric Nursing, 8(3), 150-8, Graff, M.IL., Vemnooij-Dassen, M., Thijssen, M. er al (2006) Community based occupational ther apy for patients with dementia and their caregivers: randomised controlled trial. British Medical Journal, 333. 1196, Haight, B.X., Bachman, D.L., Hendrix, 8. ef al (2003) Life review: treating the dyadic family unit Wwith dementia. Clinica Psychology and Psychotherapy, 10, 165-74. Haight, B.K. & Bumside, (1993) Reminiscence and life review: explaining the differences. Archives of Psychianric Nursing, 7, 91-8. Hanley, LG. (1981) The use of signposts and active training to modify ward disorientation in elderly patients. Journal of Behaviour Therapy and Experimental Psychiarry, 12, 241-7. Hanley, .G,, McGuire, RJ. & Boyd, W.D, (198i) Reality orientation and dementia: a controlled tel of two approaches. British Journal of Psychiatry, 138, 10-14, Haughic, E., Milne, D. & Elliot, V.(1992) An evaluation of companion dogs with eldetly psychiatric patients. Behavioural Psychotherapy, 20, 367-72. Head, D., Portnoy, S. & Woods, RT, (1990) The impact of reminiscence groups in two different settings. dnternational Journal of Geriatric Psychiatry, 5, 295-302. Heiss, W--D., Kessler, J, Mielke, R. etal. (1994) Long-term effects of phosphatidylscrine, pyrtinol, and cognitive training in Alzheimer’s disease. Dementia, 5, 88-98, Heyn, P, Abreu, B.C. & Ottenbacher, K.J. 2004) The effects of exercise training on elderly persons, with cognitive impairment and dementia: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 85, 1694T0d. Hill, R.D., Evankovich, KD. Sheikh, J. & Yesavage, J.A. (1987) imagery mnemonic training in a patient with primary degencrative dementia. Psychology and Aging, 2, 204-5. Holden, U.P, & Woods, R-T. (1995) Positive Approaches to Dementia Care, 3rd edn. Churchill Liv ingstone, Edinburgh, Hopman-Rock, M., Staats, PG.M., Tak, E.C.PM. & Droes, R.M. (1999) The effeots of a psychomotor activation programine for use in groups of eognitively impaired people in homes for the elderly. International Journal of Geriatric Psychiatry, 14, 633-42. Husband, H.J. (1999) The psychological consequences af learning a diagnosis of dementia: three case examples, Aging and Mental Heath, 3(2), 179-83, ution, S., Sheppavt, L., Rusted, J.M. & Ratner, HLH, (1996) Structuring the acquisition and retrieval environment to facilitate learning in individuals with dementia of the Akzheimer type Memory, 4, 113-30. Josephsson, $., Backman, L., Borell,L, ef at, (1993) Supporting everyday activities in dementia: an intervention study. International Joumnad ef Geriatric Psychiatry. 8, 395-400. Kasl-Godley, J. & Gatz, M. (2000) Psychosocial interventions for individuals with dementia: an integration of theory, therapy, and a clinical understanding of dementia, Clinical Psychology Reviews, 20, 755-82. Kipling, T., Bailey, M. & Charlesworth, G. (1999) The feasibility of a cognitive behavioural therapy _ghoup for men with mild/anoderate cognitive impairment, Behavioural & Cognitive Psychotherapy. 27, 189-93. Kitwood, T. (1990) The dialectics of dementia: with particular reference to Alzheimer's disease. Ageing and Society, 10, 177-96. Kitwood, T. (1997) Dementia Reconsidered: the Person Comes First. Open University Press, Buck- ingham. Knapp, M., Thorg dementia: cost: Lam, DH. & Wo ational Journ, Lekeu, F,, Linden, free/etied recall ciated Disordei Little, A.G., Volan: dementia. Biri Livingston. G., Jot to the managen 162(11), 1996. Loewenstein, D.A. impaired Alzhe Psychiatry, 12( Lord, TR. & Gam 76, 451-5, Marshall, M. (200; McCuny, $M. Gi tor Alzheimer’ 53, 793-802, MeBvoy, CLL. & Gerontologist, McGilton, KS. Ri in a now envire McLellan, BLL. (1 Neurviogy, Vol Miesen, B.MLL. (1 & BML. Mies Miesen, B.MLL. (1 ‘ment theory. dr Mortis, R.G. (199 of the Clinical 2, Morton, 1. & Bleat International J Neal, M. & Barte Cochrane Libre Newitouse, PA. E Parkinson's dis, NICE-SCIE. (200° Social Care: Ci Norberg, A., Mel the final stage 315-23, Olazaran, J,, Mua! and mild t0:m Onder, G., Zan cholinesterase Psychiatry, Onell, M., Specto of maintenanc International J OrsulicsTeras, $. residents with imil LOL ‘op ys!Rejomoray “\waye pur jwoueseBue VO sioayo :eNUOUTEP poouEApH Ipled SMAPS! ava wiay-3uny 40} sanranse paseg-Hossawopy (9002) ‘F2 *dumnD *B “SH ‘9pnE “S “sHsOP-oHINSICY 1S-9r “02 LuDnpksy aviouaD fo pratop jouowsoUAatY ‘eaauiap pis ajdoad 30) 8 Surmotros (LSD) £de191p uoHE|NMEHS apo aourEauTEL Jo ssatiannooygo-aqy SupuuMexo ApmIs OpEd y (COOL) "W'sPOOM 7 “TWONULs.oNy, “y Toads "IN TNO ‘SOP “LI MunNOsSy Jo jpumor ysttig “jou poyjonucs paspuopuel :esvasip S 1oUNOUEZTY uy SHOr.GYU asELASaUM OUD Tim poungunos Adviaqy uonswayo Syypsx (6002) 79 19 "sf “MUKODPED “O “NaUEZ "D “PUD E6-RhC7 £9 \GSO]aUNAN “aseasID sKTAUT}Y ayEiepOUL OF PILE PUL LOW WY wonUaA aN soWOUT-AAULUBOD Jo SIYaUDAT (YOO) 12 19 “A “Brody “A “AUNIN “Tf *TBIEZEIO ce-SIe “ez ‘saipnig Smeiny fo pruinog jonommuasuy kpms rowioydxa we wenueRap 30 aBeIS [wUL) 24 uy woneiuasoud roafqo poe Yano) “arsnex oy suomaeay (9361) ‘> ‘PANTY 7p IA “'V RIOCION, “uopuor ‘sous||9Ox3 [PONY Pur YPIEOEL J SMUGUT TACOMA Tp 9L]OpIAD JOLT) “9402 101905 uw yypoogy i s4aun stay pry BaueWiag ys agtoag Binstoddns :riautag (9002) ‘ALOS-AOIN 907 TY Busy pup sine sonmadeioMp 103 suonwoyiun -SosbasIp 5, uosuPyAea putes rauoUZty Wy MaRTATOAT WeNSAS JTUOOIN (L661) “CAL WAST "Y “TANGY “Vid ‘ASOOPHANT “sasaxrtty ‘Sts 7 IEA MOE "Z ands] ‘&sBIqy"| NED aug, “(malsat aueayoog) eauaWad Joy deren, uONMPTEA (4007) ‘a MBUAONLE BW. “TEN “OE-LE “9 uwupisg dtuInLie9 Jo jpuner ouotoULEIE -Kpmis joyed v cenuauwap ur Adesomp Gomeplyea jo ssouaANDouFe aT, (1661) O “weLURRLA|E 31 ONO rag ~G1 7 4d Saysaypm ‘svog 29 KOT MYO “SOON, “LA "Pa) SuHaAy fo kBvjoypasg tosnn4y ay JO yooqpupyy ul "enuauxop pareyas pu aseasip S.routTauTy yo ABojoYDASMosnaH Buy, (9661) D'H SLOW ES-LHL gunn ley 2}sIDLI00 fo joumog jrwomenstenuT KIOoKp WOK yarns 5,kqjnog pur woyextp stared go wotsttOtor4d ain ‘asvastp s,rOUNTaUZTY (E661) “TA USAIN ‘96-86 ‘dd “uopurr “@Bpapnoy (Uo THAT. souor +9 spe) Dywoniagy my Suapi-au0.y wt ‘enaataap pure Koaqy TwauyoENy (2661) “TICE ASAIN “06-291 “de “UopuoT “ouoisBuuary naamysy “{KireEKO “£7 HsEAS TW SP9) [TOA “jaw onli Wt “oulaipont Aayeqestp Jo sojdioud ayy pur aYA (C6GTY AT ELD BL PL ZOr-S6E “CIEL umryaiv DuoUa fo jounos woUauy siongnTE eseiarseIyoK uo siuoned oswosip JoMNoyETy pane ‘Kipqnu jo" wonempquqar aanuuBo> (FgQz) °y "eA. “L's "eer “Vy ‘opaKaaW V"E WHaIsUaMa"L 1202-9661 (CDZ9T ‘Kuonptsy fo joumop uvouioury ‘vuauap 30 sulodurks aynwyoXsdomou Jo yauadeuBU ap OF saypvodde jwolRojayoded jo wxo14as atremIansKs (SOOT) 12 12D ‘Buoy “Y "HOIsUYOG "D "UOISSUIATT TLL St MoqO YON ho} fo jouer ysis wTELIEP ‘y}uos uy womsttsopuT mou Jo UONTaTOL aL (OREI) "WATT PWC KeqswIOH “Fd 'SUEIOA “O'V “ALT ‘So-SE LT ‘suapuasty prio Buywresy, (6002) “AT ‘SHORAE 78 “a WopsBorT “WES “UNDA TERE, “pL Sigaty puo . old 6ST “AS “Boqorka027 fo joumog “ern ywowUl payjonuod ¥ Sidomed wAUeLLAp Payrpow pu we tu uoyssandop 4 Mam PeIOLANKPR (L661) W'S “SUNDA “f “oHOWON “OY wopsfo| "7 “UAL, Te-S1OT 06e “wOUDHIOSY WIPER ITA spe. wouauy fo poumor (w. po|forwto> pozimopues 8 -oseastp JaUTIAYa|Y OHEA stuovted aE WAU Saw jxoyaeyoa std 2s1519%%{ (6902) "19 “y “NopSBOT “W'S “UNM, "A"T ‘SUOAID 1 "HAL ‘ava 10) wesdox ‘O1-E1p “1e usITojojuaiery -aseasip s,loulourry wi worssaxlap 4o sounvag) 30} suOMUoA.OMUL (emoIAEyDR-2ADITED (1661) “G ‘MOsdwON-FOUFUUED Wy “UAL, 1 woronpqouay 59-651 “ZT W]Oay Buisiny us yawdasoy eAUAUeP ‘enuI9p 104 won! {nya stuoprsar suror Ssana yo saryuqe feuotoung uo uyusEa (TPS 30190)}9 LL CET) WA wade, ‘s-chT PI 6 uononugoyay jwarsoqoyaCodacnay “9seasIp 5,s9uNUZTY TH SOUEGAMSIP [CINOAByAR pour mau ede jo wwouaBeueur a4 Ur uoHExBjal ajssnW sassvasBong (6661) “CL “Pura, W'S WoRrEpLY "PKS ' L6-StR dd uonsog, ‘S9alg IA “CeaIUEZARD “|W ‘Pa) SeaueP>SAANENY fo pwumos jouoss ‘aayeuory ayy, ur ‘suroys&s ung pur ‘snduseoodday ‘Aiowayy (g661) ‘TA “UATAOUY, 3 "AT ‘uns ‘aioe Jo feu |e “OSL “Kaponpoks,] puo ia8unseunayy «Bojoanay fo poumog oveasip 5 ouuratry pe pe spostH0} KBSPI> Ropioo aaneauay pur Suno§ ur Surpoota onneioossn yo sompeus INH (EOE) 10 29 wa ‘WORLD “aT “sare “Wy Bayo 3 wpa] ‘Stoneayana FAG, aouraupuon 209) prguowogy yu aydoag 01 (15.9) Kdbioys, uounyuns aayuusiory soffg 01 PuuuisSoug daaisy paseq -oouapng uy :aouataffig’ P Suyopy (9002) Wi T8109 °A *sPOoAK “7 “UASULUBIONL “Y “IOIIadS PS-BPE “ERT “Cuonpatsg fo Journog ystiuig “Teen pattonues pasnuopuey zenuaWap tpl opdoad 205 ounwesBoxd Kétsayp WoL] ‘rurys aqiiaioa poseg-couspiaa ue jo Aovougel (E002) 70 19° “SPOON “7] "UasMUIEIOYL, "Y ‘s0}290§ LG-LLE “CHIDITT “You NgDYay so!FojoyasdaxnaR)“wHUDUIP HBL ajdoad 10g sande pasoq-uornui0o ooumesfoxd paseq-2ouspiao we jo Zanoysd pur juaudoyonacy Aparerqeyas aq woNEIUU Alex, wD (197) “A ‘SPOON 79 °S ‘SLAC "WW “IFO “Y ‘oIads soqmmuay wats VILNIWAC CNY SNOLLNIAYBINI TYIIDOTOHDASA ays548 HANDBOOK OF THE CLINICAL PSYCHOLOGY OF AGEING Woods, B., Spector, A., Jones, C. et al. (2005) Reminiscence therapy for people with dementia (review), The Cochrane Database of Systematic Reviews, John Wiley & Sons, Chichester. Woods, B., Thorgrimsen, L., Spector, A., eal. (2006) Improved quality of life and coguitive stimu. lation therapy in dementia. Aging and Mental Health, 10, 219-26. Woods, RT, (1998) Reminiscence as communication, in Reminiscence in Dementia Care (ed, Schweitzer), Age Exchange, London, pp. 143-8, Woods, R-T. & MeKiernan, F (1995) Evaluating the impact of reminiscence on older people with dementia, in The Art and Science of Reminiscing: Theory Research, Methods and Applications (eds B. Haight & J. Webster), Taylor & Francis, Washington. pp. 233-42, ‘World Health Organisation (1998) International Classification of lmpairments, Disabilities aud Fland- icaps. Available at www. who.int/msa/mnh/emslicidh/introduetion hen, Yale, R. (1995) Developing Support Groups for Individuals with Early Stage Alzheimer's Disease: Planning, Inplementation and Evaluation, Health Profession Press, Baltimore. Yale, R. (1999) Support groups and other services for individuals with early-stage Alzheimer’s disease, Generations, 23, 51-61 ‘Zanetti, Ou, Frisoni, G.B., DeLco, D. etal. (1995) Reality orientation therapy ia Alzheimers disease: useful or not? a controlled study. Alzheimer Disease and Associated Disorders, 9, 132-8. ‘Zasit, $.H,, Femia, E.E., Watson, J. et al, (2004) Memory Club: a group intervention for people with early-stage dementia and their care-partners. Gerontologist, 4, 262-9. Zasit, S.H., Zarit, LM. & Reever, K-E. (1982) Memory training for severe memory loss: effects on senile dementia patients and their families. The Gerontologist, 22(4), 373-7. BOs s 78g Br